title: Endoscopic retrograde cholangiopancreatography with rendezvous cannulation reduces pancreatic injury.
abstract: OBJECTIVE
  To examine whether rendezvous endoscopic retrograde cholangiopancreatography (ERCP) is associated with less pancreatic damage, measured as leakage of proenzymes, than conventional ERCP.
  
  
  METHODS
  Patients (n = 122) with symptomatic gallstone disease, intact papilla and no ongoing inflammation, were prospectively enrolled in this case-control designed study. Eighty-one patients were subjected to laparoscopic cholecystectomy and if intraoperative cholangiography suggested common bile duct stones (CBDS), rendezvous ERCP was performed intraoperatively (n = 40). Patients with a negative cholangiogram constituted the control group (n = 41). Another 41 patients with CBDS, not subjected to surgery, underwent conventional ERCP. Pancreatic proenzymes, procarboxypeptidase B and trypsinogen-2 levels in plasma, were analysed at 0, 4, 8 and 24 h. The proenzymes were determined in-house with a double-antibody enzyme linked immunosorbent assay. Pancreatic amylase was measured by an enzymatic colourimetric modular analyser with the manufacturer's reagents. All samples were blinded at analysis.
  
  
  RESULTS
  Post ERCP pancreatitis (PEP) occurred in 3/41 (7%) of the patients cannulated with conventional ERCP and none in the rendezvous group. Increased serum levels indicating pancreatic leakage were significantly higher in the conventional ERCP group compared with the rendezvous ERCP group regarding pancreatic amylase levels in the 4- and 8-h samples (P = 0.0015; P = 0.03), procarboxypeptidase B in the 4- and 8-h samples (P < 0.0001; P < 0.0001) and trypsinogen-2 in the 24-hour samples (P = 0.03). No differences in these markers were observed in patients treated with rendezvous cannulation technique compared with patients that underwent cholecystectomy alone (control group). Post procedural concentrations of pancreatic amylase and procarboxypeptidase B were significantly correlated with pancreatic duct cannulation and opacification.
  
  
  CONCLUSIONS
  Rendezvous ERCP reduces pancreatic enzyme leakage compared with conventional ERCP cannulation technique. Thus, laparo-endoscopic technique can be recommended with the ambition to minimise the risk for post ERCP pancreatitis.
authors.affiliation: Fredrik Swahn, Lars Enochsson, Lars Lundell, Johan Permert, Magnus Nilsson, Urban Arnelo, Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, S-141 86 Stockholm, Sweden.
authors.forename: Fredrik
authors.initials: F
authors.lastname: Swahn
authors.forename: Sara
authors.initials: S
authors.lastname: Regnér
authors.forename: Lars
authors.initials: L
authors.lastname: Enochsson
authors.forename: Lars
authors.initials: L
authors.lastname: Lundell
authors.forename: Johan
authors.initials: J
authors.lastname: Permert
authors.forename: Magnus
authors.initials: M
authors.lastname: Nilsson
authors.forename: Henrik
authors.initials: H
authors.lastname: Thorlacius
authors.forename: Urban
authors.initials: U
authors.lastname: Arnelo
mesh_terms: D000328:Adult; D000368:Aged; D000681:Amylases / Q000097:blood; D015415:Biomarkers / Q000097:blood; D043424:Carboxypeptidase B / Q000097:blood; D016022:Case-Control Studies; D002404:Catheterization / Q000009:adverse effects; D016009:Chi-Square Distribution; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects / Q000379:methods*; D017081:Cholecystectomy, Laparoscopic; D003124:Colorimetry; D004797:Enzyme-Linked Immunosorbent Assay; D005260:Female; D042882:Gallstones / Q000175:diagnosis / Q000601:surgery*; D006801:Humans; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010179:Pancreas / Q000201:enzymology / Q000293:injuries*; D010195:Pancreatitis / Q000097:blood / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D011446:Prospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014357:Trypsin / Q000097:blood; D014362:Trypsinogen / Q000097:blood
chemical_list: D015415:Biomarkers; C064831:PRSS2 protein, human; D014362:Trypsinogen; D000681:Amylases; D043424:Carboxypeptidase B; D014357:Trypsin
keywords: Common bile duct stones; Intraoperative endoscopic retrograde cholangiopancreatography; Pancreatic amylase; Procarboxypeptidase B; Trypsinogen-2